By Gary Evans, Medical Writer

A hospital system in Minnesota has fired approximately 50 healthcare workers for refusing flu shots, igniting a battle with a nurses’ union that is filing grievances to restore personnel to their jobs.

As a previously announced mandated policy reached a final deadline for vaccination in November, the workers were dismissed. As a result, some 99.5% of Essentia Health’s remaining 13,900 employees had been immunized, approved for an exemption, or were in the exemption process, says Rajesh Prabhu, MD, an infectious disease physician and chief patient quality and safety officer at Essentia Health in Duluth, MN.

The hospital confirmed that approximately 50 healthcare workers were terminated, but did not provide more specifics on the cases. Religious and medical exemptions are allowed within the flu immunization policy based on written documentation, Prabu tells Hospital Employee Health.

“We follow the CDC guidance for what is considered a contraindication to influenza vaccination including allergic reaction to the influenza vaccine or any of its components, or a severe adverse reaction to the vaccine,” he says. “We follow guidance from the Equal Employment Opportunity Commission (EEOC) regarding what constitutes a religious-based exemption.”

Under a 2016 EEOC ruling, six healthcare workers fired for refusing flu shots for religious reasons won back pay and offers of reinstatement from Saint Vincent Hospital in Erie, PA. The EEOC alleged “discrimination because of religion by failing to accommodate their sincerely held religious beliefs and practices that prevented them from receiving the influenza vaccine.”1 (For more information, see the story in the February 2017 issue of HEH.)

With prior voluntary policies resulting in a vaccination rate in the 80% range at Essentia, the healthcare system decided to go to a mandated policy, Prabu says.

“The CDC and state public health departments have continued to urge all healthcare personnel to get immunized against influenza,” he says. “Many healthcare organizations, just like our own, have been unable to achieve high levels of immunization without a required influenza immunization program.”

Based on analysis performed prior to implementing the mandate, Prabhu and colleagues found that some 600 healthcare organizations that require influenza immunization were achieving much higher vaccination rates.

“We knew that we could and should do better for our patients,” he says. “The CDC reported that Minnesota ranks 44th in the nation when it comes to healthcare personnel flu vaccination.”

Indeed, data collected by the CDC’s National Healthcare Safety Network show that 81.4% of healthcare workers in Minnesota were immunized for flu in the 2016-2017 season. In other states, percentages ranged from Alaska’s low of 75.2% to a high of 97.1% in Colorado.2

The Minnesota Nurses Association (MNA), a union that represents some 2,000 Essentia nurses, announced it will file grievances to win back the jobs and lost wages. The MNA favors allowing worker choice, but is not against flu vaccination per se, says Rick Fuentes, MA, an MNA spokesman in St. Paul.

“We maintain that voluntary, incentivized flu shot programs work much better than mandated policies,” he says. “Employees with medical or religious objections to the flu shot, including allergic reactions, however mild, should be exempted.”

The union argues that voluntary immunization programs can result in high participation, even on par with mandated policies. While some may take issue with that claim, a voluntary program at the University of Virginia in Charlottesville has reached high vaccination levels while allowing a broad range of exemptions.

“We have very high immunization rates — upwards of 95%,” says Joshua Eby, MD, medical director of employee health at UVA. “Even though it’s not mandatory, we have a highly motivated chief medical officer who puts the word out each year and really motivates the employees to get their flu shots.”

In looking to chip away at that 5% who opt out of flu immunization, Eby found something curious in the exemption records over the years. Workers who opted out gave different reasons for an exemption in different years, suggesting that they were not necessarily subject to ongoing medical conditions or bound to deep-set beliefs. The standard form the hospital has used for years allows exemption for allergic reactions, anaphylaxis, a history of Guillain-Barré syndrome, or a self-declared personal or religious belief. A physician note only is required for a claim of anaphylaxis.

Eby and colleagues originally termed this pattern “flip-flopping,” but changed it to the more neutral sounding “inconsistent exemption” for a poster presentation at the IDWeek meeting recently in San Diego.3

“Employees who are inconsistent exemptors might choose a personal exemption one year and an allergy exemption another year, and even choose to get the vaccine the following year,” he says. “You wonder how strong that personal belief is.”

The issue is being addressed in general education, but individual employees are not being asked to explain the discrepancy, he says.

“We’re just trying to understand what’s going on and see if we can learn something from it to improve our education,” he says. “We want to respect our employees’ personal beliefs, but we also want to keep in mind the need for safety in the environment we work in. We are not planning on addressing any individuals and we de-identified the data.”

The Imperiled Patient

Against the rights of the one we have the needs of the many, who in this case are frail patients who may be exposed to healthcare workers with influenza. Though some have questioned how much a vaccine of varying annual efficacy really protects patients, the CDC reported in a study last year that 1% of flu cases reviewed were acquired in the hospital.4 Another study found that in hospital settings, inpatients exposed to at least one contagious healthcare worker were five times more likely to develop hospital-acquired influenza-like illness than those with no similar exposure.5

A well-known national advocate of the medical and ethical duty to be immunized for seasonal flu is William Schaffner, MD, professor of preventive medicine at Vanderbilt University in Nashville.

“We do not wish to transmit influenza to our patients,” he says. “The secondary reason, which is also important, is when influenza strikes we in healthcare are committed to being as healthy as we can be, so that we can provide the needed care to patients. The best thing we can do to achieve those two goals is to get vaccinated. We recognize that it is not a perfect vaccine but we should not make perfection the enemy of the good. We can do a great deal of good by using influenza vaccine optimally each season.”

Though battles similar to the one unfolding in Minnesota can be expected, the momentum for mandatory flu immunization programs is increasing as a host of professional medical groups and associations now advocate the practice.

“You have to define mandates by institution, but there is now a substantial list of 10 to 15 professional organizations that clearly have supported immunization in healthcare and endorsed mandates in some form,” he says.

As other facilities adopt mandated policies, public pressure may be applied to neighboring institutions that have voluntary immunization but worse vaccination rates.

“If local healthcare worker immunization rates become part of the public record, then the hospital leadership is really quite interested in making sure that their institution is somewhere at the top,” Schaffner says. “Local reporters in our neck of the woods have looked at those data, and it is quite clear that institutional leaders do not want to be in the caboose of the train. They will be asked, ‘Why is it that all the other hospitals in the community can do it and you cannot?’ That becomes uncomfortable to leadership and should be uncomfortable to the healthcare workers who work for the institution.”

As a vaccine advocate, Schaffner is generally against non-medical exemptions to the seasonal influenza shot.

“In general — including daycare and school attendance — I’m in that group that thinks that religious and personal belief exemptions should not apply,” he says.

That said, iterations of mandatory policies will differ by institution, with the program adopted at Vanderbilt favoring counseling and communication over outright dismissal.

“Although we do not fire people, we do have a short list of valid exemptions from healthcare worker immunizations,” he says. “They are principally medical. If our workers in submitting their reasons for exemptions do not fulfill those, they are reviewed by a small committee and then their supervisors offer them counseling in that regard. With this encouraging kind of firm, ‘tough-love’ approach, we have now achieved well over 90% compliance.”

Adopted two years ago, the Vanderbilt flu shot policy requires a fair amount of institutional consensus on the front end regarding the exemptions.

“Then it takes the willingness to put in the time and effort to counsel and persuade the healthcare workers,” Schaffner says. “Each year it becomes easier, and it is just another part of the institutional culture.”

Working Sick

Another nuance to this issue is that healthcare workers who acquire flu may still report for work due to a variety of reasons that include cultural and work pressures.

“Presenteeism — if people have symptoms, but can manage them, they will come to work anyway,” Schaffner says. “There is that great tendency, but immunizing people reduces the risk. There have been studies that also show an immunized healthcare workforce has fewer absentee days.”

Regarding presenteeism, a recently published study6 found that 41.4% of 1,914 healthcare workers with influenza-like illness (ILI) still showed up for work for a median of three days, reports lead author Sophia Chiu, MD, MPH, of the National Institute for Occupational Safety and Health.

“We reported 44.6% working with ILI being vaccinated during the season,” she says. “There were 29.2% working with ILI who reported they had not been vaccinated. However, we did not ask them specifically about when they were vaccinated relative to their episode of illness.”

In any case, the findings underscore the importance of clear sick leave policies, with ILI defined in the study as fever, cough, and sore throat.

“The CDC recommends that people not work until they have been afebrile for at least 24 hours,” Chiu says. “Some of the most common reasons [sick workers] gave is that they could still perform their job duties, and they didn’t feel badly enough to miss work.”

Some of those who worked sick also reported a sense of duty to help their co-workers, and difficulty in finding coverage. Healthcare institutions should identify and address any misconceptions about working while ill, which may be tied to the work culture and expectations of their colleagues, Chiu says.

“There are cultural and social norms about when we go to work,” she says. “The policy should say, this is when you should stay home. We found in our background research that healthcare personnel who are aware of their institution’s outbreak control measures are less likely to work while they are symptomatic.”

REFERENCES

1. U.S. Equal Employment Opportunity Commission v. Saint Vincent Health Center. Civil action No. 16-224 Erie. U.S. District Court for the Western District of Pennsylvania, Sept. 22, 2016. Available at: http://bit.ly/2hjr7WR. Accessed Nov. 30, 2017.

2. CDC. 2013-14 through 2016-17 Influenza Seasons Health Care Personnel Vaccination Trend Report. Sept. 28, 2017. Available at: http://bit.ly/2AInVPr. Accessed Nov. 30, 2017.

3. Richey M, Sifri C, Eby J. Characteristics of Health Care Workers That Decline Influenza Vaccination for Varying Reasons. IDWeek 2017. Oct. 4-8, 2017, San Diego.

4. Cummings CN, Garg S, Nenninger EK, et al. Hospital-Acquired Influenza Among Hospitalized Patients, 2011-2015. IDWeek 2016. Oct. 26-30, 2016, New Orleans.

5. Vanhems P, Voirin N, Roche S, et al. Risk of influenza-like illness in an acute health care setting during community influenza epidemics in 2004-2005, 2005-2006, and 2006-2007: a prospective study. Arch Intern Med 2011;171:151–157.

6. Chiu S, Black CL, Greby SM, et al. Working with influenza-like illness: Presenteeism among US health care personnel during the 2014-2015 influenza season. Am J Infect Control 2017;45(11):1254-1258.